Fergus Cullen: Chuck Morse's Medicaid plan is what leaders do

Gov. Maggie Hassan says not expanding Medicaid will cost the state a million dollars a day in federal funding. Conservatives worry that when — not if, but when — the feds renege on their promises, New Hampshire taxpayers will be left holding the bag for a million dollars a day instead.

More often than not, the biggest fights in politics are over little issues that are more symbolic than substantive. The battle over Medicaid expansion is that rare thing: a big issue worthy of a big fight.

New Senate President Chuck Morse, R-Salem, is not enthusiastic about expanding Medicaid as an entitlement program. The governor’s plan would add some 58,000 people to Medicaid, another step toward the fulfillment of the progressive vision of public insurance for all. Such an expansion will bankrupt us in due course and Morse is more than willing to have a big fight about that.

So why is Morse out with a plan that would accomplish much of what liberals say they want — increase access to health insurance for another tranche of poor people, and utilizing federal funding to do it?

Because Morse didn’t go to Concord to watch the Merrimack River roll by — and because doing nothing will lead to an expansion plan that is worse. “It’s real easy to say no,” Morse told me, perhaps thinking about how other Republicans handled battles over health care in Washington this year. It’s much harder to offer a compromise plan that gives liberals the choice of achieving the end they say they want while doing so through conservative means.

The conservative alternative to big government health care has to be more than “Don’t get hurt, don’t get sick, and don’t get old.” Republicans can’t be seen as uncompassionate toward people who are poor and vulnerable. We’re talking about individuals making less than $16,000 a year and families with kids trying to get by on less than $32,000. Morse understands that conservatives should be for more people having access to health insurance, and act as though they agree it is a problem that many poor people, including children, aren’t covered.

That’s why Morse unveiled a conservative alternative plan to Medicaid expansion this week to deal with the issue. It’s a balanced approach that expands access to health insurance for the same population the governor targets, but does so by relying on private insurance instead of government-run entitlement programs.

Morse’s plan also includes a critical state taxpayer protection: The program would sunset in three years, when the federal government’s current promise of 100 percent funding is scheduled to end. If the program is to continue after that, a future Legislature will have to act anew and can make adjustments, including ending the experiment, if the costs are too high or the federal government tries to shift costs to the state.

Morse’s plan would help low-income individuals who lack coverage to get it through employer plans when available, and through the new state exchange for those who cannot get coverage through an employer. Premium support — subsidies to buy the insurance policies — would be paid for using the federal funds Washington is dangling as a carrot, and would require a waiver Morse thinks the state can get. This funding would be deposited into a new trust fund so it is not commingled with general fund money, where it becomes fungible and can be siphoned off or raided to pay for other things.

Morse’s plan also requires covered individuals to have skin in the game through deductibles and co-pays. Hospitals and providers — a sector that is one of the state’s largest employers — will prefer Morse’s plan because it relies on private insurance, which pays better than Medicaid while offering better plans for consumers.

Morse knows he’s taking a political risk by even talking about a plan than can be construed as supporting an expansion of a large government program. He knows he’s opening himself up to criticism from the Ted Cruz, just say no faction within the base.

But Morse is also willing to walk away from a bad deal as well. If the governor insists on an entitlement model of Medicaid expansion, she risks getting nothing. If she’s smart, she’ll take the deal.

Fergus Cullen, a freelance columnist, can be reached at fergus@ferguscullen.com and followed on Twitter @FergusCullen.